Court Denies Claim for Plastic Surgery Benefits after
Gastric Bypass

June 27, 2008 (PLANSPONSOR.com) - The U.S. District
Court for the District of Vermont has denied a health plan
participant's claim that IBM Corp. should pay for her plastic
surgery to remove excess skin following gastric bypass
surgery.

The court rejected Laura Murray’s argument that
IBM’s rejection of her claims for the second set of
surgeries was unreasonable because it was inconsistent
with its previous decision to provide coverage for the
first set of surgeries. Murray claimed that IBM applied a
higher standard to the second approval request, even
though the “merits for the second surgeries [were]
the same for the primary surgery.”

The court pointed out that under guidelines of the
American Standards for Plastic Surgery (ASPS) guidelines,
symptoms indicating medical necessity may be present in
one part of the body but not in another. The court also
pointed out that IBM’s self-insured plan requires proof
that reasonable attempts at conservative treatments
failed, and ruled that Murray had not provided evidence
of this.

In its opinion, the district court ntoed that
evaluating the medical necessity of each set of surgeries
separately was reasonable and proper in light of the
accepted medical standards. “IBM’s decision that the
first set of surgeries was medically necessary but that
the second set of surgeries was not does not constitute
an inconsistent application of the plan,” the opinion
stated.

Murray
also argued
that the plan administrator’s decision to deny benefits was
unsupported by substantial evidence because it relied on
the opinion of an independent medical review firm rather
than the opinions of Murray’s treating physicians. Citing a
previous court decision, the district court noted “a plan
need not accord the insured’s treating physician greater
deference than a plan’s retained physician. Although plan
administrators may not ‘arbitrarily refuse’ to credit the
reliable evidence put forth by a claimant, there is no
‘heightened burden of explanation . . . when they reject a
treating physician’s opinion.'”

The court said the file reveals that IBM’s decision
to deny coverage was supported by substantial
evidence.